OIL & GAS SERVICE CONTRACTOR SUPPLEMENTAL

Transcription

1 AMERICAN UNDERWRITING MANAGERS 365 Miron Drive, Suite D Southlake, TX PHONE: (817) FAX: (817) OIL & GAS SERVICE CONTRACTOR SUPPLEMENTAL (To Be Accompanied By ACORD Forms As Applicable) GENERAL INFORMATION AND OPERATIONS Named Insured: Physical Address: Mailing Address: Complete Description of Operations: Individual Partnership Joint Venture Corporation Other: Years in Business: Year of Experience of Principals: List all states where Applicant has any operations: Average Number of Field Operations Employees: Field Operations Gross Payroll: $ Gross Receipts: $ What percentage of work is offshore? % What percentage of work is wet or marshland? % ENGINEERING & INSPECTION INFORMATION Contact: Name Title Address Phone Number Do you have a formal/written safety program? Yes No Do you have a Safety Director on staff? Yes No Are periodic safety meetings conducted? Yes No If yes, how often? Are all employees required to attend? Edition Date: May 17,

2 SUBCONTRACTOR INFORMATION 1. Indicate below the operations you typically subcontract out: Cementing Electrical Instrument Logging Mechanical Mud Logging Rathole Drilling Rig Moving Rig Erection & Dismantling Running Casing Site Preparation Welding Wireline Services Other: 2. Indicate which of the following you require of your Subcontractors: Certificate of Insurance Additional Insured status for yourself on subcontractor s insurance Waiver of Subrogation provisions on subcontractor s insurance Subcontractor insurance endorsed to be primary 3. Do you require subcontractors to sign and have a Master Service Agreement (MSA) on file in your office before they begin work for you? Yes No (a) If yes, what form of MSA do you use? API IADC Other (attach a copy) (b) If yes, describe your company MSA guidelines: do you require MSA s from all subs? Only from subs who perform specific operations? Based on expenditure threshold? Based on other factors? 4. List the insurance coverage and limits you require for subcontractors: Coverages General Liability Blanket Contractual Products / Completed Operations Underground Resources Pollution Auto Liability Workers Compensation Umbrella Liability Limits Required OPERATIONS BY CLASSIFICATION COMPLETE ALL APPLICABLE SECTIONS & QUESTIONS In the spaces provided indicate by placing an (X) mark for the operations the Applicant is involved in. Also, provide the Gross Payroll and Gross Receipts for those operations the applicant is involved in. Oil or Gas Wells Servicing by Contractors (13821s / 98161) Bleeding or Vending $ $ Blowout Preventor Installation $ $ Casing Packing $ $ Dredging.. $ $ Fishing. $ $ Gas Processing / Squeezing / Sweeting $ $ Gauging $ $ - 2 -

3 Hot Oil. $ $ Hydrostatic Testing $ $ Nitrogen / CO2 Injection $ $ Packer Installation.. $ $ Painting / Sand Blasting $ $ Paraffin Treatment.. $ $ Pipe Fitting / Straightening / Threading / Cutting $ $ Pile Drilling. $ $ Plumbing. $ $ Salt Water Disposal $ $ Does the Insured own the property where the disposal wells are located? Yes No Does the Insured own and/or operate the salt water disposal well sites? Yes No Does the Insured s Auto Policy provide Pollution coverage for sudden & accidental spills of salt / brine water? Yes No Does the Insured allow other operator s or contractor s to dispose of salt water into the Insured s SWD Wells? Yes No If yes, does the Insured require proof of an Auto Policy which provides Pollution coverage for sudden & accidental spills of salt / brine water? Yes No o Is the Insured named on the Auto policy as A. I., with WOS? Yes No Tank Cleaning. $ $ Vacuum Truck $ $ Welding $ $ Wireline - Explosive $ $ Wireline - Other.. $ $ Well Completion. $ $ Well Plugging.. $ $ Workover Tubing/Pumps. $ $ Other: $ $ 1. Number of Hot Oil Units: 2. Number of Vacuum Units: 3. Number of Salt Water Hauler Units: 4. Number of Wireline Units: 5. Number of Workover Units: 6. Painting / Sandblasting: % In Shop % In Field 6a. What safety steps are taken for overspray? 7. Welding / Cutting: % In Shop % In Field 7a. What percentage of the applicant s operations involve welding? - 3 -

4 7b. Number of years experience as a Welder? 7c. What welding industry standards does the applicant operate under? 7d. What does the applicant Weld? 7e. Does the applicant do any welding on pipelines or containers which have previously, or still carry any flammable liquids or gases? 7f. Does the applicant do any hot tap work? If yes, who is responsible for closing valves and bleeding pipelines or testing of containers to make sure they are safe for welding operations? 7g. Percentage of new construction % vs. repair and/or maintenance %. 7h. Any welding over-the-hole? If yes, what percentage of work is over-the-hole? % 7i. Does the applicant do any welding in refineries or petrochemical plants? 7j. List the companies for which the applicant operates under a contract or agreement to do welding. ******************************************************************************* Gas or Oil Lease Work by Contractors - Not Lease Operations (13911s / 98152) Backhole / Backfilling... $ $ Land Cleaning $ $ Road Building $ $ Levee Construction $ $ Slush Pit Construction.. $ $ Flowline / Waterline.. $ $ Lease Beautification.. $ $ Pump Installation / Service $ $ Other: $ $ In addition to Lease Work, does the Applicant do any street or road work for land development, residential development, or commercial development projects? Yes No Applicant Gross Payroll Gross Receipts Oil or Gas Wells - Cementing (13861s / 98154).. $ $ Number of Cementing Units: - 4 -

5 ********************************************************************************** Oil or Gas Wells - Acidizing (13861s / 98153) $ $ Number of Fracturing / Acidizing Units: ********************************************************************************* Oil or Gas Wells Cleaning or Swabbing NOC (13881s / 98155)... $ $ In Town (13872 / 98156).. $ $ Number of Cleaning / Swabbing Units: Oil or Gas Wells - Instrument Logging or Survey Work ing Wells (13841 / 98159) $ $ Number of Logging Units: * Oil or Gas Wells - Perforating of Casing (13891s / 98160) $ $ Number of Perforating Units: Oil or Gas Pipeline Construction (98423 / 98425) Interstate... $ $ Intrastate. $ $ 1. What is the annual amount of pipeline constructed that is less than 4 inches in diameter? Miles 2. What is the annual amount of pipeline constructed that is 4-10 inches in diameter? Miles 3. What is the annual amount of pipeline constructed that is more than 10 inches in diameter? Miles 4. What percentage of pipeline that is above ground? % 5. What is the average depth pipeline is below ground? Feet Inches - 5 -

6 Geophysical Exploration (13831 / 95358) Seismic (Explosive). $ $ Oil or Gas Wells Supplies or Equipment Dealers (50871 / 15188) New $ $ Used. $ $ Mud. $ $ Chemicals $ $ REQUIRED INFORMATION: Complete list of products and/or equipment. Copy of all Material Safety Data Sheets on all chemicals sold. 1. Does the applicant sell products/equipment as a broker, who does not take possession of the products as products are shipped to the buyer directly by the manufacturer or distributor? 2. Does the applicant modify products/equipment, or repackage any products/equipment with the applicant s own label? 3. If yes, please describe. ********************************************************************************* Oil or Gas Wells Supplies or Equipment Rentals (50871 / 15188) Rented Without Operators (73913s / 11208). $ $ Rented With Operators (73911s / 11207).. $ $ REQUIRED INFORMATION: Complete list of products and/or equipment being rented. Copy of the Rental Agreement / Rental Contract. 1. Does the applicant require the renter to provide Certificate of Insurance, with liability limits of $1,000,000? * - 6 -

7 DECLARATION and SIGNATURE I have read the above Application. I declare that to the best of my knowledge and belief the statements and information in this Application and any attachments thereto are true, accurate and complete. This information is given to the insurer for the specific purpose of obtaining insurance coverage. It is agreed that if any information given in this Application or in any attachments is materially false, inaccurate or incomplete, the insurer may deny coverage or cancel the policy. Signature of First Named Insured Title Date Signature of Producer Date - 7 -